Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised as required for three residents. For one resident with diagnoses including diabetes mellitus, chronic kidney disease, and peripheral vascular disease, a pressure ulcer developed and resolved, but the care plan was not updated to reflect the resolution of the wound, despite a subsequent assessment indicating no unhealed pressure ulcers. Another resident with a prothrombin gene mutation and hypertension was receiving anticoagulant medication, but the care plan incorrectly listed pulmonary embolism as the diagnosis for anticoagulant use, even though there was no history of pulmonary embolism in the medical records. A third resident, admitted with repeated falls, dementia, and cervical spondylosis, used a neck collar for a period and later began exhibiting behaviors that led to the initiation of an antipsychotic medication. The care plan for this resident included the use of the neck collar but was not updated to include the new behaviors or the use of antipsychotic medication, despite quarterly assessments being completed. Staff interviews confirmed that the care plans should have been revised at the time of these changes or assessments.